Cleft Palate Repair with Orbicularis Oris Plus Buccal Mucosal Flap: A New Double Layered-Technique

Recurrent oronasal fistula closure is a challenging phenomenon that has been managed with many surgical or flap techniques, such as local, regional, and distant flaps, with various modifications. Despite these options, the ideal method to repair this kind of chronic fistula has not yet been established. It is difficult to repair because recurrent surgical repairs or interventions cause this region to become more fibrotic with less vascular tissue, which considerably reduces the likelihood of closing this kind of fistula. For this reason, surgeons and researchers continue to work to overcome these obstacles by using more regional, vascular, and neighboring tissue. Classic cleft palate repair techniques use double-layered, nasal, and oral side closure and even a three-layered technique (e.g. plus levator veli palatini and tensor veli palatini muscular repair) in the soft palate region. Hence, we used partial orbicularis oris muscle with enough vascular supply to repair the nasal side and cheek mucosal flap to repair the oral side as a double-layered repair technique. Two years later, during routine patient follow-up, no complications were identified, and the patient’s satisfaction with this treatment was acceptable.


Introduction
Cleft lip and palate is a common entity found in oral and maxillofacial surgery that is usually repaired during childhood.However, it sometimes re-opens, especially in the anterior part of the palate, and can cause dentofacial deformity (e.g.skeletal Class III malocclusion) [1][2].
The cause of dehiscence of the oronasal track may be iatrogenic; it can be due to a complication of surgical repair, which has a relatively high incidence rate of 4-34%, or radiotherapy [1][2][3][4][5].In addition, recurrent surgeries for a chronic oronasal fistula reduce the likelihood of successful repair due to excessive tissue fibrosis.Moreover, diminished blood flow, increasing age, and decreasing regenerative capacity during this period present challenges [1][2][3].
Concerning the complications of recurrent surgeries, oronasal fistulas have been repaired with many surgical techniques.Honnebier et al. [6] classified the techniques employed for fistula closure into two groups: mucoperiosteal flaps in a single shape and hinge flaps including additional tissue from the region nearby the fistula as buccal mucosa or tongue tissue [3].
In addition to these techniques, faced with dehiscence of the flap, the closure technique emerges as a buccal mucosal flap, orbicularis oris flap, tongue flap, and free flaps as dermis or mucosal and myomucosal flaps, bone, and conchal graft.If a successful result cannot be achieved, prosthetic obturation of the fistula can be made [3].Tiwari and Sarabahi [2] used the or-bicularis oris muscle with mucosa for the closure of an oronasal fistula as a single-layer technique.
In this technical paper, we present a case of a chronic oronasal fistula that had been repaired many times previously that we treated with a new double-layered technique.

Case Presentation
An 18-year-old male patient was referred to Gaziosmanpaşa University, Faculty of Dentistry, Orthodontics, and Oral and Maxillofacial Surgery Clinic for skeletal Class III malocclusion and anterior palato-alveolar fistula.He had undergone multiple operations throughout childhood and adolescence.Clinical and radiological examinations were carried out by both Orthodontics and Oral and Maxillofacial Surgery Clinic, and these clinics decided to conduct multidisciplinary treatment.
He had no relevant systemic illnesses.An informed consent form regarding the patient's treatment steps and the free use of patient data for scientific or academic purposes was completed.Orthodontics and Oral and Maxillofacial Surgery Clinic decided on maxillomandibular double jaw surgery plus surgical closure of the fistula using a chin bone graft and primary sutur-ation of the adjacent mucoperiosteal flap after initial classic orthodontic treatment was completed.These plans were carried out, but the fistula finally was reopened.Therefore, after removing the failed bone graft from the surgical site, we used a new technique with double-layered flaps (Figure 1-3).This included using partial orbicularis oris muscle for nasal floor closure (Figure 1) that originated from the modiolus and extended to the surgical area.A cheek mucosal flap was used for oral side closure due to not debulking much of the inefficient volume of the lip that originated from the right cheek, and it was extended to the surgical area.At his follow-up appointment, two years later, successful healing of the chronic oronasal fistula was observed.
During this period and in the follow-up period, the removable prosthesis was constructed and applied to the patient (Figure 4).The patient is undergoing regular follow-ups.The only limitation of this technique is that we applied it to only one patient with dehiscence.Nevertheless, according to the literature that contains similar techniques working successfully, this new technique could be used in future problematic oronasal fistula closures, especially in anterior palate cases, to obtain more preci-se more precise results [2].

Conclusion
In cleft palate patients, recurrent surgeries are sometimes very challenging due to the usual fibrotic and less vascularity in the surgical site.In like these situations, cleft palate repair with vascular orbicularis oris muscle, plus buccal mucosal flap might be a good option for surgeons.

Figure 1 :
Figure 1: Pretreatment view of the patient, a: Preoperative extraoral view of the patient, b: Preoperative intraoral view of the patient showing the oronasal fistula, c: Appearance of the partial orbicularis oris flap, d: Appearance of the suturing of the flap to the nasal side of the fistula, e: Appearance of the cheek flap suturing to the oral side of the fistula, f: Two years later view of the surgical area showing the uneventful healing

Figure 2 :
Figure 2: Representative drawing of the surgical technique, a: Appearance of the just incised of the fistula edges, b: Appearance of the uncovering of the orbicularis oris muscle, c: Dissecting of the partial orbicularis oris flap, d: Suturing of the partial orbicularis oris flap to the nasal side of the fistula, e: The suturing of the mucosa over of the remaining of the orbicularis oris muscle, f: Appearance of the cheek flap suturing to the oral side of the fistula

Figure 3 :Figure 4 :
Figure 3: Pre-treatment and post-treatment extra-oral view of the patient, in which the functional lip movement could be seen